rravkin@aol.com

DBritt,
We have experienced this at our facility enough so that we have a protcol of washing the sceening cells in saline and reconstituting in saline as well, and repeating the screen. The repeat is usually negative. I have some reservations about this procedure because there would be a difference in buffering range between MTS and saline. And I am not sure I accept the idea that a patient is reacting specifically with the MTS diluent either. I think that the correct way to describe this anomally is to say that a reaction is taking place in the presence of MTS but not in the presence of Saline. We have had no trnsfusion problems, however. So the MTS, with respect to certain patients, does cause what appears to be clinically insignificant reactivity.

We don't have bags returned to us.  We take off 2 segments when we retype the units and save for a month, 1 week in each bag.  It's easy to find by when it was retyped in the computer and there are only four small bags to check for the correct date.

labgirl153,
If you don't mind, you seem the type that needs evidence for yourself, so I would recommend a little experiment at your convenience; make a serial delution of your Anti D reagent using Saline and cross this with standard Rh pos 3-5% reagent cells for varying lengths of time; ie Series 1:2 to 1:32 (to start) and run several sets of these reactions, one set at 15min 37C inc., another at 30min 37C inc, and 45min 37C inc, and lastly 1hr 37C inc. Wash and coombs and check for agglutination. Let us know what you get.

Cannot post the entire article due to copyright restrictions, but most institutions have access to NEJM through their library. If not, shoot me an email at neil_blumberg@urmc.rochester.edu and I'll send along the .pdf.
If you are transfusing 40-60 platelets a day, giving ABO identical to group O and A individuals should be relatively easy.  When patients are changing  ABO blood group it becomes more difficult. We avoid transfusion ABO antigen and/or antibody that is incompatible with either original recipient type or donor type.  Usually means washed group O red cells and platelets.  That's the bad news. It does require time and effort, and as you say, med techs are in short supply.  Here's the good news. If you transfuse ABO identical or washed compatible platelets you will use between 30-50% fewer platelets per patient, increasing your supply and decreasing your cost/problems. You will also use next to no HLA matched platelets (we used 3 out of 6,000 one recent year), you will have fewer febrile and allergic transfusion reactions, you will have fewer red cell as well as HLA antibodies made in recipients, and you may reduce TRALI and TACO.  Obviously you have to have universal leukoreduction to start with.  Selective leukoreduction misses about 50% of the  patients who will become refractory, probably due to missed or delayed diagnosis of hematologic malignancy, aplastic anemia, etc.  But the big attraction is you will have less bleeding, although that mainly affects the patients and the docs and nurses at the bedside.  

When you transfuse ABO major incompatible, which seems to be the default due to fear of hemolysis from minor incompatible, you don't get any increments, you use lots of platelets and the patients bleed more. (see references below)  Bleeding causes lots of harm, but also impacts the blood transfusion service for obvious reasons.  So figure out a way to start giving patients with aplastic anemia and acute myeloid leukemia who are newly diagnosed only ABO identical platelets and that will be a great start for the patients and the transfusion service.  Those patients will bleed less, need fewer platelet transfusions, have fewer transfusion reactions, will not have positive DATs, and will likely survive their hospitalization and disease at higher rates if our experience is typical.
And if you cannot give ABO identical or washed platelets free of incompatible cellular and soluble antigen and free of incompatible ABO antibody, start out with minor incompatible platelets (e.g., O to A) rather than ABO major incompatible (e.g., A to 0).  The risks of hemolysis are not negligible (about 1 in 800) but are less serious and severe than having life threatening bleeding or refractoriness which occur more rapidly with ABO major incompatible in all likelihood.  There's a ton of antibody that is incompatible with antigen transfused when we give A platelets to O recipients which means each antigen winds up with a ton of antibody making huge immune complexes.  When we  transfuse antibody incompatible we are transfusing a small amount of antibody into a recipient with huge amounts of antigen, so the size and number of immune complexes is probably smaller. These are my best guesses that we've been making exactly the wrong decision when we give ABO mismatched platelets. Best to avoid any, but major mismatched provides no hemostasis, minimal to no increment and is associated with increased bleeding mortality in the study from Columbia (David Roh and colleagues https://pubmed.ncbi.nlm.nih.gov/33649761/).  But ABO identical is not that hard for larger centers for the 85% of patients who are group O or A.  You just have to start small, get the hang of it, and then extend to other blood groups and other diseases than leukemia, MDS and aplastic anemia (including transplants, particularly allo--transplants). All those tables of how to select ABO mismatched platelets for transplant recipients are well intentioned but scientifically without evidence.  Avoid infusing incompatible antigen and antibody as much as possible, and delay transfusion when ABO identical will be available within hours.  Give priority to patient well being over inventory management. Give reduced doses, which work just as well.  Get a Terumo or Haemonetics washing device and wash with PAS. It's a big set of changes, but neither terribly expensive nor rocket science. The dogmas and expert opinion about universal leukoreduction and ABO matching of transfusions are now proven to be tragically mistaken.
 
https://www.ashclinicalnews.org/news/from-the-blood-journals/written-in-blood/outcomes-abo-incompatible-platelet-transfusions-patients-intracerebral-hemorrhage/
https://pubmed.ncbi.nlm.nih.gov/11399821/
https://pubmed.ncbi.nlm.nih.gov/21414009/

Couldn't agree more, particularly, certainly in my own experience, many inspectors have a minimal amount of experience in the field (particularly Reference Laboratories), but feel they have to comment to justify their employment, even though they don't actually understand or know what they are talking about; not all, but far too many.

Most developing clinically significant alloantibodies still react at 37oC, and so trying to detect them at room temperature is more or less futile as, in most cases, all you will detect are antibodies that  you do not want to detect, such as cold-reacting anti-M, anti-N, anti-P1, etc, which would be a waste of time, reagents and, most importantly these days it would seem, money.
Most polyspecific or broad-spectrum AHG reagents these days are a mixture of anti-IgG and anti-C3d (particularly in the UK).  They do not contain anything but the merest hint of an anti-IgM (certainly, they would not be CE-marked for anti-IgM).  The other thing is that I am prepared to bet quite a lot of money that your laboratory is using EDTA-anti-coagulated samples.  This means that the Ca++, Mg++ and Mn++ ions are all chelated from the plasma, which means that the complement pathway cannot be initiated in vitro, so, even if the de novo antibody was capable of "fixing" complement, the anti-C3d would not detect such an antibody anyway.
Therefore, as the number of recently transfused patients who are developing antibodies not yet detected by normal serological techniques who have been fatally affected by a further transfusion hasn't been great (zero in fact) and the same applies to pregnant ladies, stick to trying to detect clinically significant antibodies at 37oC using monospecific anti-IgG.
GOOD QUESTION THOUGH - SHOWS YOU ARE THINKING!

At the end of the quoted policy above is this caveat:
"Increase in temperature alone should not always constitute justification for a transfusion reaction work up. Nursing judgment should be used in evaluating symptoms and notification of physician."
Here, we occasionally have problems with workups not being done, or direction from the blood bank to stop transfusions, against hospital policy.  This is because there is sometimes a tendency to excuse reactions, such as a temp increase, to something other than an acute reaction to the transfusion. 
Now, every facility has to go by their own policy, but I would rephrase this as:
"A significant increase in temperature, that may be attributable to some other cause, shall not constitute justification for ignoring what may be a life-threatening acute transfusion reaction.  Nursing judgment should be used in evaluating symptoms only after consultation with the Laboratory Blood Bank, and attending physician."
Scott

I am a little worried about the fact that there is no serological cross-match if the mother has made an atypical antibody.  The reason I say this is because it is well-known that when a person makes one antibody, they often make more than one.  If a mother makes, for example, an anti-K, which is easily detected, she may well also make another antibody specificity, such as an anti-Dia.  As the Dia antigen is a low prevalence antigen in most populations, it could well be that the Dia antigen is not expressed on either the screening cells or the antibody identification panel cells - in other words, it may not be detected.  Even if the baby does not express the Dia antigen on its red cells, the maternal anti-Dia will still go through the placenta, and so this anti-Dia will still be in the baby's circulation.  If, the unit to be transfused is K-, but Di(a+), the baby could well have an unexpected haemolytic transfusion reaction, which could be avoided by a serological cross-match against the mother's sample.  Once the unit has been cross-matched, and found to be compatible, then aliquots from the same unit of blood can be safely transfused without a further cross-match, but I feel that, for the first transfusion from any unit of blood, a serological cross-match should be performed.

I was going to ask if distance traveled had anything to do with this distinction, transported or stored. But it is actually the container that is being transported and the blood is stored within this container. If the container is sealed such that the stored blood is not in any contact with the elements then the stored blood would be good until it's expiration provided the temp is maintained in this container. I think that the container's ability to maintain the appropriate temper for a given time and the time it takes to travel a given distance is probably where the question of transport and storage originates. But the temperature maintenance is a container issue and not the units of blood "stored within."
If a pregnant woman travels a given distance can we think that the fetus she is carrying is transported or stored?
 

When a person undergoes a bone marrow transplantation, their own bone marrow is "destroyed" by radiotherapy, chemotherapy or a combination of the two.  Donor bone marrow, sometimes of a completely different blood group is then introduced into the circulation of the recipient, and the stem cells migrate to the marrow and start to clone.  as they clone and develop, so the developing cells (red, white and platelet) start to come out into the circulation (although not all at once - the red cells are usually, but not always first).  At the same time, the patient's own red cells are gradually removed from the circulation by a form of apoptosis, called eryptosis, by splenic macrophages.  Eventually, the donor's red cells will make up 100% of the circulating population (although the patient may require transfusion support for some time), and by the time this happens, if the donor's blood group differs from that of the recipient, the recipient's blood group will, effectively, have changed to that of the donor (at least, this is true for all antigens that are intrinsic to the red cell membrane - those that are adsorbed onto the red cell surface from the plasma, for example, Lewis, Chido/Rodgers, will stay the same as the recipient's original type).

It very much depends on what tolerance you have on your machines, but I would be amazed if it was that close, and did not cross your measurement of uncertainty.  I would have telephoned the ward anyway.

Hey Exlimey, very well put. 

We simply used a beaker with water and ice and maintained the temperature during the 15 minute incubation period. 
This procedure was brought to us by a perfusionist who had been an MLS prior to becoming a perfusionist.  She developed these procedures as part of a project when she was in perfusionist school.

Just out of curiosity, how has this been working out for you?  Any significant problems or negative patient outcomes do to this practice?  What caused you to pose this question?  Also, how big and/or busy is your facility?  Is your testing manual or automated?  
On the surface I would have to answer your question with a NO but a little more info would help.  I've always been a "if it ain't broke..." kind of guy.  If your system is simple and works well for you why seek to complicate it.   

I was going to ask if distance traveled had anything to do with this distinction, transported or stored. But it is actually the container that is being transported and the blood is stored within this container. If the container is sealed such that the stored blood is not in any contact with the elements then the stored blood would be good until it's expiration provided the temp is maintained in this container. I think that the container's ability to maintain the appropriate temper for a given time and the time it takes to travel a given distance is probably where the question of transport and storage originates. But the temperature maintenance is a container issue and not the units of blood "stored within."
If a pregnant woman travels a given distance can we think that the fetus she is carrying is transported or stored?
 

Hi Malcom, not withstanding the reference given, if there is indeed any contradiction, but I had a co-worker who practiced Blood Bank at a hospital where part of their type an screen practice was a 4C incubation for all open heart pre surgical patients. The idea being that the docs wanted to be aware of any cold agglutinins because during the surgery, and as a consequence of the proceedings, the patient's body temp would drop. To what degree, and how it compares to the referenced recommendation you site I do not know. I hope that retirement is treating you well and best wishes, Ronald. 

This started being a hot topic 10 - 15 years ago.  It started in the AABB and they were fine with calling the coolers transport but then the FDA got involved and their stance was that it was storage and to my knowledge they have not varied from that stance.   That was when I started looking into the "vending machine" blood band refrigerators for the OR.  Sadly they were too expensive for our penny pinching administration so the OR had to be satisfied with blood delivery via pneumatic tube that was measured in seconds!  They were devastated!  

Sorry Tabbie, but low prevalence antigens are antigens that are only expressed on the red cells of a few individuals in a particular population, or even worldwide, whereas low affinity antigens are antigens that may be expressed on any number of individual's red cells, but which do not "fit" well with their cognate antibodies.  In other words, there is only a weak link between the antigen and antibody, and these links can also easily be broken.  This is because antibody/antigen reactions follow The Law of Mass Action.  In the case of a low affinity antigen, the reverse reaction (the dissociation between the antigen and antibody) is at least as quick and easy as is the forward reaction (the association between the antibody and the antigen).  In this case, YES, repeated washing with saline can wash away the antibody, and YES, the eluate may be unreactive, but this is very rare.  That notwithstanding, the commercial companies have to write this into their inserts, to cover themselves in law.

A few comments:
Beware of running strong Cold agg samples initially cold and the subsequently warm.  Most Haematology analysers sample from the bottom of tube, with strong Cold Aggs (especially those anaemic) this may result in a significant volume of concentrated RBC's being removed from tube, when sample warmed and re-analysed then patient may become significantly more anaemic! (So we only allow 5 g/L difference between runs).  We use Middleware rules to identify these known patients and prevent these samples to be run 'cold'. Why worry about not reporting RBC, MCV, MCH etc in this small set of patients, clinically they need accurate WBC / Diff, Hb & Plts. Beware of using warmed diluents, this will cause MCV shift (Dependant on analyser), so will need to validate procedure.

We were using the Sysmex analyzers as the time.  They use a sodium laurel sulfate detergent in the hemoglobin channel which fully lyses the red cells and also breaks up lipids.  I see your concern with uneven RBC distribution--I have heard of cases where the RBCs are so agglutinated that it doesn't even aspirate a uniform sample.  I would guess in that case you might wash an aliquot of the sample before diluting? 

Malcolm - while I totally understand where you are coming from, in the trenches of the small hospitals antigen typing prophylactically can lead to very increased pricing of red cells (if done from the blood center).  Also, most smaller institutions do not carry reagents for antigen typing, which, if they perform it - albeit rarely - they are supposed to enroll in surveys that demonstrate competencies in doing so (another exhorbitant expense).  Such typing is not mandated in the US of A though I do note that institutions with active sickle programs do perform extended typings due to the fact that these patients are going to be transfused periodically. 
Good question for sure.

According to BSH Guidelines (and work performed by such luminaries as the late Prof Patrick Mollison - who knew a bit about blood transfusion!), those who have already made a clinically significant atypical alloantibody are more likely than others to make other specificities.  It is for this reason that a patient who has made such an antibody is no longer eligible for a transfusion of blood selected by electronic issue (or, as people STILL insist on wrongly calling it, computer crossmatch - GRRRRRRRRRRR!!!!!!!!!!!!).
The more antibodies in a person's plasma, the more difficult it is to sort out all the various specificities, and the more difficult it is to supply antigen negative blood.  As a (former) Reference Laboratory Chief, I prefer either to work on really easy samples, or really, really complex samples, but not on samples with two or three antibodies present, particularly where one or more are avoidable Rh and/or Kell Blood Group System (BGS) antibodies.
Therefore, although not mandated by either the BSH Guidelines, or, indeed, the UK Transfusion Services as a whole, as a personal preference, I would advise that Rh and Kell BGS,antigens are matched (particularly as, if the individual has already produced an antibody - probably from a previous transfusion - although other stimuli are "available" - and needs another transfusion, the chances are that this individual will require further transfusions in the future, if not actually become transfusion dependent).
I fully admit that this is a purely personal point-of-view, however, I would be more than a little annoyed if I was to be sent a sample at 3 o'clock in the morning, to sort out an additional, but avoidable specificity.  It is, however, down to you.

I would suppose (after a quick bit of research), that since a K is only going to vary by only 1 or 2 mEQs, that its inclusion makes little clinical difference.  That's as long as the reference range is appropriate for whatever calc you are using (such as: 8-16 without K+, and 10-20 with it).
Actually now that I think of it, the original omission probably had to do with making the equation a bit easier to do on the fly.  I imagine that as people used to do it in their head before the advent of computerized analyzers and reporting systems that now give the anion gap automatically.
Scott

The thing is tkakin, that most examples of anti-C (anti-Rh2) are not; they are actually anti-Ce (anti-Rh7)!  This is largely because almost every red cell that causes immunisation against the C antigen expresses both the C and e antigens as a result of having the RHCe gene, rather than both the C and e antigens as a result of having both the RHCE gene and the RHce gene (which is why both the DCE and dCE haplotypes are so rare).  On the other hand, monospecific anti-e is comparatively common.
So, your lady's plasma is more likely to contain anti-Ce and anti-e, rather than anti-C and anti-e.  As a result, if, as yan xia suggests, you would undoubtedly adsorb out the anti-e, but you still would not know if the remaining antibody specificity is anti-C or anti-Ce (or, of course, a combination of the two).
Anyway, the specificity really doesn't matter.  The point is that, as you suggest, the individual titres of what ever antibodies are present are totally irrelevant.  Normally, an antibody, such as anti-C (or anti-Ce) or anti-e, are not going to cause clinically significant haemolytic disease of the foetus and newborn, until the titre reaches 32, and it really doesn't matter whether the specificity of the antibody is anti-C, anti-Ce or anti-e.  Your Pathologist should explain this to your OB doctor to get him or her off your back (actually, to be honest, your OB doctor should already know this, but hey, life ain't always like that!).

Maybe you can adsorb the anti-e with ccee cells, then to see if there are still reaction with Ce cells, then you can figure out if there are anti-C here.